Onboarding 4
Recognizing and Communicating CAUTI
Case Scenario 1: Mrs. Smith
Directions:
1. Divide into small groups of 2-3 people.
2. Groups should work through each part of the case scenario, pausing for discussion before
moving to the next section.
Part 1
You are assigned to take care of Mrs. Smith, an 85-year-old transferred from the hospital 5 days ago
after falling and suffering a broken hip. She had an indwelling urinary catheter in place at the time of
transfer. The evening shift notes mention that she didn’t eat or drink much at dinner. At your morning
visit, you notice that urine is cloudy and foul smelling. Mrs. Smith states that her pain medication makes
her mouth dry and she doesn’t have much of an appetite for breakfast. The charge nurse suggests
sending a urine analysis because her decreased appetite and change in the character of her urine may
be early signs of a CAUTI. Discuss within your group.
1. Do you agree or disagree with the charge nurse? Explain.
FACILITATOR NOTES:
At this point, the Mrs. Smith doesn’t have any clinical signs or symptoms of a CAUTI. Therefore, it is not
clear that sending a urine analysis would be indicated. In addition, she has an alternate explanation for
her change in appetite—side effects of pain medication, d change in urine character and dehydration.
Use this question to review the CAUTI definitions and the criteria listed on the CAUTI surveillance
worksheet.
2. What additional information about Mrs. Smith would you like to know before ordering a urine
analysis?
FACILITATOR NOTES:
If a CAUTI is suspected, staff should perform a clinical history and exam to determine if localizing signs or
symptoms are present. Actions which could be taken include:
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Checking vital signs
Asking about new complaints
Performing an exam of the abdomen and suprapubic area
In addition, this is an opportunity to ensure the catheter is functioning correctly, review indication for its
continued use and consider whether it is still necessary.
Use this time to explore how details about the catheter use is are documented at your facility. When
residents are transferred from the hospital with an indwelling urinary catheter, does your facility receive
information about indication for use and the date of insertion? If not, how is that information be
obtained? Does your facility have consistent documentation of urinary catheter indication and date of
insertion when the device is placed in the long-term care facility? If not, how could that be improved?
3. Who else should be included in the discussion?
FACILITATOR NOTES:
Discuss the communication process in your facility when a CAUTI or UTI is suspected. Does your facility
use a standard communication tool (e.g., SBAR) for sharing information with providers (e.g. physicians,
physician assistants, nurse practitioners)? Discuss how information might impact provider decisions.
Part 2
The charge nurse calls the physician to discuss Mrs. Smith’s condition. The physician decides to follow
the advice of the charge nurse and orders a urine analysis and culture.
1. Is it likely that the analysis results will demonstrate presence of white blood cells in the urine
(e.g., positive for leukocyte esterase)? Is it likely that the urine culture will grow bacteria?
ANSWER: YES
Explanation: Given the presence of the urinary catheter, it is highly likely that the analysis will be
abnormal and the culture will be positive.
2. Will the findings on the urine analysis and culture help decide if Mrs. Smith has a CAUTI?
Explain.
ANSWER: NO
Explanation: The presence of pyuria and bacteriuria are NOT enough to define a symptomatic CAUTI. The
presence of pyuria and asymptomatic bacteriuria are very common in individuals with indwelling urinary
catheters. Remember, signs and symptoms are key to distinguishing ASB from CAUTI.
3.
Are there other measures that the charge nurse or physician should have considered in the
management of Mrs. Smith?
FACILITATOR NOTES:
The physician could have evaluated the current pain medication to see if it is contributing to her loss of
appetite. Oral hydration may help improve the volume and character of her urine output. Close
monitoring of vital signs and ongoing evaluation for other signs and symptoms while hydrating would
ensure that if her status declined, it would be detected quickly. The analysis and culture is often an easy
first step in assessment, but it could also hinder the identification of identifying the true cause of a
resident’s problem.
4. How would you manage Mrs. Smith’s condition based on the information provided thus far?
Would the results of the urine testing change your management plan?
FACILITATOR NOTES:
As mentioned above, reviewing Mrs. Smith’s pain medication regimen, increasing oral hydration and
monitoring for new signs/symptoms should be considered.
Part 3
The urine analysis was positive for pyuria and showed evidence for bacteria (positive nitrites). The
culture is still pending. When Mrs. Smith’s physician was notified of the results, she requested vital signs
be checked and fluids increased in case of dehydration. She also recommended increased monitoring of
vital signs and screening for new signs/symptoms of CAUTI during the next 24 hours.
Mrs. Smith had normal vital signs until later that afternoon after she returned from physical therapy.
During her transfer from the wheelchair to her bed, her urinary catheter collection bag, which had been
hooked to the arm of her wheelchair, became tangled in the wheel. As she moved to the bed, she
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developed acute pain, which subsided after a few minutes. About 30 minutes after retiring to bed, new
urine had not collected in her bag and she has begun complaining of lower pelvic discomfort when the
catheter bag was handled.
1. Was Mrs. Smith developing new signs of a CAUTI? Are there other explanations for her
signs/symptoms?
FACILITATOR NOTES:
Acute lower pelvic pain could be a symptom of CAUTI, but given the history of catheter trauma during her
transfer from the wheelchair to bed, this is more likely due to dislodgement of the catheter. Given that
the catheter is not draining urine, consider whether the tubing has become kinked or the balloon has
been pulled out of place.
2. What might be steps to address Mrs. Smith’s new signs/symptoms?
FACILITATOR NOTES:
Replace the catheter if the device is not working correctly. Continue to monitor for signs/symptoms of
CAUTI given that the urine flow was obstructed.
3. Were there issues with her catheter’s handling during and after physical therapy that may have
contributed to her signs/symptoms?
FACILITATOR NOTES:
While there may not be adequate information in this clinical scenario to know what exactly was done to
the catheter during physical therapy, knowing that someone raised the collection bag above the level of
the bladder during transport to the room, may indicate that some of the staff may not know how to
handle this device. Raising the collection bag above the bladder allows urine to flow back into the body
which increases the risk of CAUTI. Also, allowing the tubing to get tangled and pulled can cause serious
injury and discomfort for residents and disrupt the functioning of the device.
Use this time to review the catheter maintenance and insertion checklists. Discuss opportunities to
educate all staff about safe catheter handling, including hand hygiene and gown/glove use for insertion
and emptying of collection bags.
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